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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700974
Report Date: 09/13/2021
Date Signed: 09/13/2021 03:30:36 PM

Document Has Been Signed on 09/13/2021 03:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:A FAMILY AFFAIR CARE IFACILITY NUMBER:
342700974
ADMINISTRATOR:MITCHELL, KASSIAFACILITY TYPE:
740
ADDRESS:1917 ONEIL WAYTELEPHONE:
(916) 919-4590
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY: 6CENSUS: 6DATE:
09/13/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, Kassia MitchellTIME COMPLETED:
04:00 PM
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On 9/13/2021, Licensing Program Analyst (LPA) Tung Truong arrived at this facility to conduct an unannounced Post-licensing inspection. LPA met with Administrator Kassia Mitchell and explained the purpose of the visit. Administrator Kassia Mitchell holds current certificate # 6020161740 and expires on 9/5/2022.

LPA observed the following posted in the entrance of the facility. See Something Say Something poster, Ombudsman poster, Reporting Requirements, Resident Personal Rights, Evacuation Routes and facility license were all posted as required.

LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms; resident bathrooms, laundry area, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. The bathrooms were in sanitary condition and properly maintained. The hot water temperature was observed to be 108.3 degrees Fahrenheit. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed knives and toxins to be locked away and inaccessible to residents. Fire extinguisher and first aid kit was up to date. LPA checked medication storage and found medication to be locked away and inaccessible to clients. LPA also conducted the infection control domain tool.

Report continued on 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: A FAMILY AFFAIR CARE I
FACILITY NUMBER: 342700974
VISIT DATE: 09/13/2021
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LPA reviewed the Personnel Policies, Abuse Reporting Procedures, In-Service Training and Medication Procedures during the Post-Licensing Inspection. Staff completed training from Assisted Living Certification. LPA observed Covid practices in place. LPA reviewed two resident records and two staff records.

The facility has Covid-19 posting throughout the facility. The facility has submitted a mitigation plan to CCLD. The facility has one central entry point, and the facility has routine symptom screening checks for residents, staff, and visitors. The facility has a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented. All staff are vaccinated.

Administrator was informed to send updated copies of the following documents to CCL within 15 days:
(1) LIC308 Designation of Administrative Responsibility
(2) LIC500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance
(6) LIC309 Administrative Organization

Per California Code of Regulations, Title 22 Division 6, Chapter 8, No deficiencies were cited during today's visit.

Exit interview held with Administrator and a copy of report given at the conclusion of the visit.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
LIC809 (FAS) - (06/04)
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